Background Pharmacist-led interventions decrease drug-related problems (DRPs) and improve clinical outcomes. Patients with multiple-drug therapy and patients transitioning across different care settings are at higher risk of experiencing DRPs.
Purpose This study aims at developing an ambulatory clinical pharmacist service at the Diabetic Hospital Out-Patient clinic focusing on medicine reconciliation and transmission of treatment updates to the community pharmacist responsible for patient follow-up.
Material and methods This is an ongoing prospective investigational study. Patients>18 years of age and having at least one anti-diabetic medication are eligible to participate in the study. The clinical pharmacist meets the patients and during a medicine reconciliation session identifies any DRPs that are discussed with the physician. A Transition of Care Document capturing any changes in medication and the current patient treatment is compiled and sent to the community pharmacy, identified by the patient, which is responsible for chronic medications follow-up.
Results Thirty-five patients have been included in the study to date. Fifty-six DRPs were identified and classified into five different categories. Lack or misinterpretation of information was the most common DRP (83%) followed by treatment not according to Joint British Diabetes Societies guidelines (63%), requirement of additional drug (52%) and inappropriate timing of administration and/or dosing intervals (37%).
Metformin (77%) and the statins (49%) were the two most common drugs requiring interventions. The hospital pharmacist provided recommendations for the identified DRPs, either verbally, in the case of educational interventions or written in all other instances. Seven out of eight interventions were accepted by the physicians.
Conclusion The DRPs identified were addressed during the intervention by the hospital pharmacist at the Out-Patients’ Clinic and the Transition of Care Document was used to transmit information on updates in treatment to the community pharmacy that follows-up the patient for chronic medication refills.
References and/or acknowledgements Pharmacy Department at the University of Malta and the Diabetic Outpatient Clinic at Mater Dei Hospital.
No conflict of interest.
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